Abnormal Uterine Bleeding

The health of the uterus is a critical issue that affects the well-being of both individuals and society as a whole. Women may encounter various problems that can significantly impact their quality of life. In the second part of my article on Abnormal Uterine Bleeding, we will discuss the causes of this condition, especially known as abnormal uterine bleeding. Abnormal uterine bleeding is a common issue experienced by many women, and it is important to be informed about its causes, symptoms, and treatment options.

What Are the Causes of Abnormal Uterine Bleeding?

• Endometrial Polyps: One common cause of abnormal uterine bleeding is the presence of growths on the uterine wall, which can protrude and are often described as uterine polyps. Most endometrial polyps are benign, and their frequency increases with age. The most common symptom is irregular bleeding, which can also occur after straining or heavy lifting. Less common symptoms include heavy or prolonged bleeding, post-coital bleeding, post-menopausal bleeding, cervical prolapse, and unplanned (sudden) bleeding during hormone therapy. Diagnosis is made through ultrasound performed by a gynecologist and, when necessary, a hysteroscopy, which involves looking inside the uterus with a camera.
• Adenomyosis (Uterine Enlargement): Adenomyosis, or uterine enlargement, occurs when uterine wall tissue is present within the muscle layer of the uterus. Patients often present with prolonged, heavy bleeding and persistent abdominal pain that doesn't respond to pain relievers. About 90% of patients with adenomyosis experience some symptoms. Possible diagnosis can be made based on ultrasound or magnetic resonance imaging (MRI).
• Fibroids: Fibroids are the most common intra-abdominal tumors in women. They typically develop in women of reproductive age and often do not cause symptoms. When symptomatic, they typically present with abnormal uterine bleeding and/or pelvic pain or pressure. Uterine fibroids are generally benign and become more common with age. Diagnosis can be made using ultrasound or MRI.
• Malignancy and Hyperplasia (Cancer and Irregularities): Irregularities in the uterine wall and uterine wall cancer can be causes of abnormal uterine bleeding. In women over the age of 35, especially those with risk factors such as chronic diabetes, obesity, or a family history of uterine cancer, and in women over 40 without any risk factors, abnormal uterine bleeding should prompt investigation for uterine wall malignancy and hyperplasia, with biopsy being recommended to rule out these conditions.
• Coagulopathy (Bleeding Disorders): Bleeding disorders often lead to heavy menstrual bleeding. The approach to identifying these patients begins with a structured medical history to assess symptoms or risk factors related to coagulation disorders. Patients who have had heavy menstrual bleeding since their first period (menarche), or who have experienced bleeding after childbirth, tooth extraction, or surgery, as well as those who bruise easily, have nosebleeds, experience frequent gum bleeding, or have a family history of similar complaints, should be evaluated.
• Ovulatory Dysfunction (Ovulation Problems): Patients with problems such as missed periods and infrequent menstruation may present with abnormal uterine bleeding. In non-pregnant women of reproductive age, this is a common cause of abnormal uterine bleeding. Various factors can disrupt ovulation, including hormonal imbalances during the early menstrual years (menarche), decreased hormone levels in the premenopausal period before menopause, polycystic ovary syndrome (PCOS), high prolactin levels, thyroid hormone disorders (hyperthyroidism or hypothyroidism), stress, eating disorders (overeating or under-eating), pituitary and hypothalamic tumors, tumors that secrete hormones in the ovaries and adrenal glands, Cushing's syndrome, chronic liver and kidney diseases, the use of hormone-containing medications, antidepressant use, antipsychotic drug use, steroid-containing drug use, and chemotherapy drugs.
• Endometrial Dysfunction: This diagnosis should be considered when there is no identifiable cause for excessive menstrual bleeding or intermenstrual bleeding in patients with regular and predictable menstrual cycles. It primarily results from molecular and cellular abnormalities responsible for regulating the volume of blood lost during menstruation. Conditions such as endometritis (inflammation of the uterine wall) and pelvic inflammatory disease (infections of the uterus, fallopian tubes, and ovaries) fall into this category.
• Iatrogenic Causes: Medications taken externally and certain medical interventions can also cause abnormal menstrual bleeding. Birth control methods that contain estrogen and progesterone hormones, monthly or three-monthly injections containing only progesterone, subcutaneous implants, and copper intrauterine devices used as contraception can lead to excessive menstrual bleeding. Hormone therapies used to alleviate menopausal symptoms, anticoagulant medications, medications that disrupt prolactin hormone regulation, and medications with steroids, as well as certain medications used for mental health conditions (antidepressants and antipsychotic drugs), steroid-containing medications, and chemotherapy drugs, are also among the factors that can cause abnormal uterine bleeding.
• Unclassified: This category includes conditions such as cesarean scar defects, which are pockets of tissue in the old cesarean section site, and can lead to prolonged menstrual cycles, persistent spotting, and heavy bleeding. Abnormal bleeding can also result from abnormalities in certain blood vessels affecting the uterine wall (arteriovenous malformations). Ectopic pregnancies in the fallopian tubes, tube cancers, tube infections, certain hemorrhagic ovarian cysts, and ovarian cancers can also present with abnormal bleeding.

Dr. Erkan Aslan

Obstetrician and Gynecologist